The SCC’s ruling on assisted death: Where do we go from here?

It has been just eleven days since the Supreme Court of Canada’s (SCC) unanimous ruling to remove the ban on physician-assisted death. This leaves 354 days until the ruling becomes law, at which point our governments, healthcare organizations, educational institutions, and healthcare professionals need to be ready to handle and implement such requests.

For years, physician-assisted death has been a highly tumultuous discussion topic in Canada, and one that we recently confronted at our annual Travill Debate at Queen’s. Yet even after a ruling of the highest court and decades of debate, this decision will be celebrated by many and denounced by others. Those who were against this ruling have argued valid points, and we must remain keenly aware of the risks involved, and work inter-professionally to help protect the vulnerable and not allow the guidelines of eligibility to slip over time.

As an individual physician and faculty member, I personally applaud the ruling. I would also note that we are fortunate to have forward-looking organizations such as the Canadian Medical Association (CMA), led by Queen’s own Dr. Chris Simpson, that have been working towards this outcome. In August, the CMA reformed its policy on physician-assisted death to support all physicians to follow their conscience when deciding to partake in such acts, as long as it is within the bounds of Canadian legislation. At that time, the CMA also declared “there should be no undue delay in the provision of end-of-life care, including medical aid in dying when it becomes legal.”1

With the official SCC ruling, the CMA now plans to move to examining “ways to support doctors who choose to participate in assisted dying with education and training.”1 Naturally, we at Queen’s University’s Faculty of Health Sciences must do the same to prepare our country’s future healthcare professionals. My personal view is that there will be many details to work out with respect to the development of very tight guidelines and the identification of appropriate mechanisms for physicians to follow their conscience. But we should not shy away from this work, and need to be progressive leaders given the brave SCC ruling.

Geriatric care specialist and Associate Professor in the Department of Medicine, Dr. Chris Frank, considers that “current medical students will need to be prepared to adapt to a new law by the time they are residents. Discussions with students and with residents in advance of the change in the federal legislation should start now. The evolution of the policies of organizations such as hospitals, the CMA, and provincial governments will obviously need to inform the curriculum along the way.”

Naturally, this leads us to ask who should be involved in this type of education. Dr. Ray Viola is a Palliative Care physician and Associate Professor in the Palliative Medicine Division of Queen’s Department of Medicine. He explains that there seems to be an impression that palliative care teams will play a major role to ensure assisted dying is used appropriately, even though the majority of palliative care physicians do not see this as a part of palliative care services. “We will need to engage all physicians to think about what this means, how it fits into their practices and the health care system in general. We should not see it as something that only certain medical disciplines will need to address. During our careers, all physicians will likely be asked. It is so very important that we resist making judgments about colleagues who choose to participate or not participate; we must ensure that dialogue occurs in a mutually respectful manner.”

It is true that it would be easy for us to assume that only palliative care specialists would be confronted with such requests, but in reality, a wide range of health care professionals will encounter patients who are facing severe, incurable, debilitating and life-threatening illnesses. Most of them will never request assisted death. And yet, how can we empathize with them if they do? There are inherent elements of empathy that cannot be taught, and yet we as a Faculty will need to provide our students with the tools to work with patients and each other in these delicate situations.

As the government refines the rules and regulations that will ensure the ethical implementation of this law, we here at the Faculty of Health Sciences will be working to prepare Canada’s future healthcare leaders for this new aspect of patient empowerment.

Share your thoughts on physician-assisted death by commenting on the blog…or better yet please drop by the Macklem House. My door is always open.

I would like to acknowledge Emma Woodman for her assistance in researching and writing this blog.

Heather F. Clarke PhD (Nursing)

Thank you Dean Reznick for this update on current and future actions as well as your thoughts on implications for medication education. I think it also be pointed out that such a ruling and subsequent legislation will also impact the education and practice of many other health care professionals, especially nurses who work most closely with physicians. Interprofessional ethics courses will be needed as there will no doubt these decisions will raise moral and ethical dilemmas for many. In addition I can see where theological educators and curriculum will need to be involved to prepare practitioners in their supportive role to both patients and health care professionals. The thoughts expressed in your blog are just the beginning of the journey.

Richard Rowland

The cowardly lawyers have foisted this onto the medical profession, so we must be careful not to foist it onto the palliative care teams. It will require careful collaboration to make sure no one is forced to act contrary to their ethics.
Hippocrates where art thou?

Peter O'Neill

We are so fortunate at Queen’s to have Chris Franks and Ray Viola who can teach the greater medical community what the new federal law will have to address; namely what “grievous and irremediable medical conditions” are, and how to determine “enduring suffering that is intolerable to the individual”. But with only 16-30 percent of Canada having access to Palliative Care , those specialists will not be able to address all Canadian patient concerns.

Moreover, while the Canadian Medical Association was quick to say that physicians would be able to have conscientious objection to this new law, the College of Physicians and Surgeons of Ontario is currently revising its policy on Professional Obligations and Human Rights and they do not provide a conscientious objection provision .
Doctors in rural settings might be without coherent federal and provincial obligations for palliative care and rights to physician assisted death.

Personally, I think it will take more than doctors to address this issue. Currently the Office of Interprofessional Education and Practice holds a very successful Compassionate Care Workshop for students in Medicine, Nursing, Rehab and Theology. This same group might be able to find the educational model to address this new law.

reznickr

You bring up many important points which underscore that the implementation phase of the potential new transformative piece of legislation will not be easy.There will certainly not be one formula that fits all, and to be sure, many health professional groups will need to be involved. I agree with your suggestion that additional education in a student’s early professional development will be critical for preparing them for the future..

Ken Gamble

You have indicated that Queens Medical School will begin to prepare its students for the legal changes brought about by the Supreme Court’s recent decision and dramatic changes in the official position stance of the Canadian Medical Association. How will medical students be trained to distinguish between laws that they ought to follow and laws that they should prudently disobey, given that governments have in the past used medical regulations to achieve odious objectives (notably in Germany and the Soviet Union)?

Ross Morton

In addition to the well accepted and legislatively supported practices of preventing conception of life and termination of life development prior to birth, we are on the cusp of embracing the termination of life prior to “natural” death.

I put my comment in those terms, not because I oppose any one of the practices on principle, but just to highlight the natural extension of the spectrum.

While we may have Faculty who can educate us on “grievous and irremediable medical conditions” , my understanding was that the prime driving force was the individual and her/his perception of the condition.

We do indeed live in interesting times. I will watch developments with interest.